ENROLLMENT APPLICATION FOR NEW STUDENTS

Accredited by New England Association of Schools and Colleges (NEASC) Madina Academy Last updated March 2021

www.madinaacademy.org

ENROLLMENT INSTRUCTIONS

The Madina Academy Board of Education requires that each student be formally registered prior to admission. The following documents will be required:

Health Assessment Record/ Completed Physical Examination by Pediatrician

Immunization Record

Copy of child’s birth certificate.

School Contract (Parent/Guardian signed statement)

Transfer of Student Documents Release Form (from previous school, if applicable)

Prior to the first day of class, the following will also be required:

I. Completed Emergency Contact FormII. Full payment for books and activities fee.

In order to best serve our students and their families, there will be a few other forms and surveys needed in the first few weeks of school. We would appreciate your cooperation in completing and submitting these forms as you receive them. Periodically the School Administration and the Board of Education reviews policies and make changes to them as needed. Accordingly, parents will be notified.

Administration

Physical Address 519 Palisado Ave.

Windsor, CT 06095

Phone 860-219-0569

Mailing Address 519 Palisado Avenue Windsor, CT 06095

Email [email protected]

[email protected]

http://www.madinaacademy.org/

mailto:[email protected]

mailto:[email protected]


519 Palisado Avenue, Windsor, CT 06095 ENROLLMENT APPLICATION FOR NEW STUDENTS

2021-2022 (Please print or type – One form per student)

STUDENT INFORMATION

Name: Gender: Male Female

Age: Date of Birth: Race: Place of Birth:

Address: Phone:

City: State: Zip:

FAMILY INFORMATION Father Step-father Guardian

Name: SS#:

Address (if Different): Phone:

City: State: Zip:

Religion:

Occupation:

Employer(s): Business Phone: Mother Step-mother Guardian

Name: SS#:

Address (if Different): Phone:

City: State: Zip:

Religion:

Occupation(s):

Employer(s): Business Phone:

Parent/ Guardian E Mail:


Marital Status of Parents:

Married Separated Married Married

With whom does child reside? Number of children in family:

Languages spoken at home:

Other Siblings: Name Gender

M/F Date of Birth Grade School

1.

2.

3.

4.

EDUCATION

School last attended: City/ State:

Grade last completed: Grade to attend in the Fall: Has the child attended a full time Islamic school before? If so, when and where?

Has your child ever had disciplinary problems, been suspended or expelled from previous school? If yes, please explain.

Has your child ever repeated a grade or had serious academic problems in school? If yes please explain.

What are your goals/reasons for enrolling your child at Madina Academy?


MEDICAL Does your child have any medical problems?

Epilepsy Diabetes Allergies Asthma Hearing Speech Vision

Heart Disease Other - Please specify:

Has your child been identified as having any learning disability or special need?

Is your child on any kind of medication?

Does your child have any allergies to any medication?

If yes, please specify:

Please use the space below to provide any other information about the student that might be helpful.

I understand that the Admissions Committee will review this application before reaching a decision. I further understand that admission into Madina Academy is contingent upon the accuracy of this application, supporting records/transcripts and no outstanding balance. I also realize that the Admissions Committee reserves the right to conduct admission tests prior to reaching a decision regarding admission. Furthermore, I agree to abide by all the policies established in the Madina Academy Handbook (which can be accessed from www.MadinaAcademy.org or which is otherwise established from time to time by the Madina Academy Board. I hereby affirm that, to the best of my knowledge, all statements made herein are true and complete.

Father’s/Guardian’s Name Father’s/Guardian’s Signature Date

Mother’s/Guardian’s Name Mother’s/Guardian’s Signature Date

http://www.madinaacademy.org/


Madina Academy does not discriminate on the basis of race, color, national or ethnic origin, or sectarian affiliation in the administration of its educational policies, scholarship programs and other school administered programs.

For Office Use Only:

Date Application Rec’d:

Check Date: Check #: Total Amount:

Application Fee

(non-refundable)

Application Reviewed By:

Remarks:


2021-2022 Tuition Rates/ Payment Options

Fees cannot be paid in installments and are payable to Smart Tuition. All fees must be paid by June 10th, 2021. Late fee of $100 will be charged if all fees are

not paid by the above mentioned date.

We also offer two payment plans

1-Three installments due at the beginning of August, January and April as follows:

2- Ten (10) installments, first installment due on August 1st, 2021 and last installment is due onMay 25th 2022.

All Payments must be made to Smart Tuition

FEE COST Due Date

Activities and Curriculum Fee Non refundable

$200/ Child Due by June 10th, 2021. Online payment to Smart Tuition.

Smart Tuition Fee Non refundable

$50/ Family* Due by June 10th, 2021. Online payment to Smart Tuition.

Technology Fee Non refundable

$85/child Due by June 10th, 2021. Online payment to Smart Tuition.

Tuition full-time students $ 6300/per student Due in accordance to selected payment plan Tuition part-time students $4200/per student

Amount due by Full-time Part-time August 1st, 2021 $2,100 $1,400

January 2nd, 2022 $2,100 $1,400 April 1st, 2022 $2,100 $1,400

Total $6,300 $4,200


TUITION CONTRACT 2021-2022

I (we) clearly understand and accept the Tuition Policy as outlined by the Board of Education (“Board”) of the Academy. I (we) understand that there are separate fees of $200 activity/curriculum fee per student, $85 technology fee per child and $50 smart tuition fee per family (only for families with payment plans) all due June 10th, the fees are Non-Refundable. Please select one of the following three payment options:

1- It is mutually agreed that the tuition for the student named will be paid in full at

the beginning of the school year.

OR

2- I/ we are not in a position to pay the tuition at the beginning of the year; it will be paid in 3 installments according to the

following payment plan of three installments;

Full-time Preschool

Monday-Friday (8AM-3:30PM)

Part-time Preschool

Tuesday,Wednesday,Thursday (8AM-3:30 PM)

Amount due by Tuition Amount Amount due by Tuition Amount

August 1st, 2021 $2,100 August 1st, 2021 $1,400

January 2nd, 2022 $2,100 January 2nd, 2022 $1,400

April 1st 2022 $2,100 April 1st, 2022 $1,400

Total $6,300 Total $4,200

OR

3- I/ we request a special payment plan. We are able to pay the tuition in 10 monthly installments,

(August 1st, 2021 – May 25th, 2022) * Delinquent Accounts: Three tuition reminders will be emailed to parents that have not paid their account according to the payment plan set up at the time of registration. In this case, students will not be allowed to attend classes until all overdue fees are paid in full also, students with delinquent accounts will not be eligible for readmission for the next academic year. The 1st installment is due on August 1st 2021 and the last installment is due on May 25th, 2022. Furthermore, I (we) agree to abide by the tuition policies and deadlines as outlined above and take full responsibility for any delinquent amounts that may be owed by us. I (we) also understand and agree that in case of a delinquent account my child (ren)’s records will not be released to any third party (including other educational institutions).

I (we) have also read and understand the Student Withdrawal Policy stated in the Madina

Academy Handbook.

*If I (we) withdraw our child(ren) from the Smart Bees Learning Center for any reason, we

agree to pay the tuition in full per this agreement.

If it is necessary to employ a professional collection agency and/or attorney to enforce or to

collect a judgment based upon this agreement, I / we will be responsible for paying all


expenses accrued including, but not limited to, collection agency fees, court fees and

attorney fees.

Tuition Withdrawal Policy:

1. Parents will be liable for 25% of annual tuition fees if student(s) withdraw by September 30th

2021

2. Parents will be liable for 50% of annual tuition fees if student(s) withdraw by November 30th

2021

3. Parents will be liable for 100% of annual tuition if student(s) withdraw after November 30th

2021

• All other non-tuition related fees (admission fees, re-enrollment fees, activity fees, technologyfees, Smart Tuition fees) will be non-refundable in any of the above cases.

Father’s (Guardian’s) Name:

Mother’s (Guardian’s) Name:

Names of other children if attending Madina Academy:

Mailing Address:

Telephone: Cell & Office &Home:

Father’s (Guardian’s) Signature Date

Mother’s (Guardian’s) Signature Date

Office use only - Received by:

Date Rec’d: Student Name:


Emergency Contact Form

STUDENT NAME: Last First Middle

GRADE:

Email Address (Both Parents’ Emails Must Be Provided):

Mother/Guardian: Father/Guardian:

Home Address:

Home Tel:

Father’s full name:

Father’s place of employment:

Father’s place of employment address:

Work Tel:

Cell #:

please check here if you like to receive text messages with school news, announcements and weather-related closures

Mother’s full name:

Mother’s place of employment:

Mother’s place of employment address:

Work Tel:

Cell #:

please check here if you like to receive text messages with school news, announcements and weather-related closures


Family Physician Name and Tel:

Person to call in case of emergency besides parents: No. NAME TEL # RELATIONSHIP 1.

2.

3.

Any allergies or medical conditions we should know about:

* IN CASE OF A REAL EMERGENCY 911 WILL BE CONTACTED FIRST THEN THE FAMILY MEMBERS WILL BE INFORMED IMMEDIATELY AFTERWARDS.

EMERGENCY MEDICAL TREATMENT AUTHORIZATION I hereby give permission for the staff / Guardian / People list in the release form to provide

simple first aid treatment to my child, when necessary.

In the event of a more serious illness or injury, I give permission for my child to be

transported to a hospital or other emergency medical facility to receive emergency medical

treatment. I also authorize ambulance/rescue squad attendants to administer such

treatment as is medically necessary, and I authorize licensed health practitioners working in

the hospital or emergency medical facility to examine and provide emergency medical

treatment to my child if warranted. I understand that I will be contacted by childcare

program personnel as soon as possible regarding any emergency involving my child.

Parent/Guardian Signature: Date:


Release Form

For the security of all students at Madina Academy we will be only releasing students to authorized persons. Please list the names of people who are allowed to pick up your child(ren). Madina Academy will not be releasing your child to anyone who is not on the list. Please include the names of people who you think will be picking up your child from time to time and in emergencies.

Child’s Name:

Grade:

No. Name Relationship Phone # 1

2 3 4 5 6

Parent’s/Guardian’s Name:

Signature:

Date:


Photograph/Video Authorization

On occasions, the school faculty may take photographs and videos during field trips and school events. These photos and videos are used for classroom scrapbooks, the yearbook, promotional displays, local newspapers, social media posts (such as Facebook), school website, and our school YouTube channel.

If you do not wish to have your child’s photograph/video taken for these above purposes, we ask that you indicate that below. If we do not receive this completed form, we will assume consent.

Internet Use Authorization

Students from Pre-K will use electronic devices in classrooms to enhance their learning experiences. We would like to emphasize that:

• The students will be closely monitored by the teacher while using the internet. • Only educational websites will be allowed and selected by the teacher. • Students are expected to work within the guidelines and expectation given to them by the

teacher. • Any student who violates any of the above polices will be denied access to the internet for

two weeks following the incident and parents will be notified. • Any Student who exchanges inappropriate websites that he/she may have access to outside

the school will face a penalty that will range from after school detention to being suspended from school for a period that will be determined based on the severity of the violation.

We would like to make sure that our students are computer literate. We will make sure that the internet gets used properly and no violations will be tolerated.

Do you give permission for your child: to have his/her picture and video taken and used for educational and promotional purposes while at school?

Yes

No Do you give your child: permission to have an email account and use the internet at school for educational purposes under the supervision of the teacher?

Yes

No Parent/ Guardian’s Signature: Date:

ENROLLMENT APPLICATION FOR NEW STUDENTS

Documents

Transcript of ENROLLMENT APPLICATION FOR NEW STUDENTS